Psoriasis: Comparing Treatments and Dealing with Feelings

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What are the latest developments in psoriasis research? Do you know all the latest treatment options that are available to you? Are the biologic treatments better than the more traditional treatments? Our expert dermatologist, Dr. Stephen Feldman, discusses the current psoriasis treatments, where we’re headed and tips for weighing your treatment options. Dr. Feldman also answers your questions and suggest and ways to cope, treat and live with psoriasis for a better quality of life.

Announcer:Before we begin, we remind you that the opinions expressed on this program are solely the views of our guests. They are not necessarily the views of HealthTalk, our sponsor or any outside organization. And as always, please consult your own physician for the medical advice most appropriate for you.

Now, here’s your host.

Ross Reynolds:
Hello and welcome to our program. I’m Ross Reynolds. Tonight, we’ll be discussing new treatments for psoriasis. Psoriasis is a frustrating problem, but fortunately many new treatments are now available. And to speak with us about those options, we have Dr. Steven Feldman, a former member of the Medical Advisory Board of the National Psoriasis Foundation. He’s also a professor of Dermatology, Pathology and Public Health Sciences and the director of the Psoriasis Treatment Center at Wake Forest University School of Medicine in Winston-Salem, North Carolina. Welcome, Dr. Feldman.

Dr. Steven R. Feldman:
Good evening.

Ross:Dr. Feldman, in the past, most psoriasis patients have looked to one or two or a combination of the following treatments: the topical treatments, which patients apply to their skin; phototherapy, where patients are exposed to light and systemic treatment; or medication. I’d like to go through each of them.

Could you talk briefly about some of the common topical treatments?

Dr. Feldman:Before I do that, let me just say that the first thing a psoriasis patient wants to do is to educate themselves about the different options. A great way to make sure you’re up to date on all the options is to check out the Psoriasis Foundation’s Web site. That way, you can find out about all the topicals, the systemics and the injectables from an unbiased source.

The topicals are terrific for people who can put medication on all their spots. Most topicals are cortisone-type medicines. There are also some vitamin D medicines such as Dovonex (calcipotriene). There’s a medicine related to vitamin A called tazarotine (Tazorac). There are some older things such as anthralin (Drithocreme, Dritho-Scalp, Micanol) and coal tar that are still good medicines.

Ross:
Generally, how effective are these topical treatments?

Dr. Feldman:
They can be very, very effective. There’s a lot of research going on in what’s called pharmacogenomics, the study of what genes determine whether somebody gets better with a certain medicine or not. Some people do great with a certain medicine and some people don’t.

But it turns out that the number one factor that determines whether somebody improves with one of these topical medicines is whether they put that medication on regularly. Psoriasis, as was mentioned, is very frustrating. It’s chronic, there’s no cure, and some of the medications that we dermatologists have been asking our patients to use have been really messy, greasy and smelly. It’s not surprising that over time, patients just get tired of them.

Even the medicines that aren’t so messy are still time-consuming to put on, and patients get frustrated. I think the major reason why the medicines work really well in some people is because those people are better about using their medicines.

We actually did a research study here. I had learned that there’s a company that sells medication bottles that have computer chips in the cap. They record when the bottles are opened and closed. They were designed to study people’s compliance and how well they took their pills. We decided to put a topical medicine in one of these bottles and give them to psoriasis patients. We found that over the course of this eight-week study, the patients used progressively less and less of the medicine over time.

We did another study with typical non research patients, and they used medicine even less than the people in the research study did. If I prescribe something that’s worse than the disease, that’s too much trouble, and that’s too messy. I don’t blame patients for not putting it on.

What we need to start doing in dermatology is to tailor the treatment to fit the patient. If the patient doesn’t like putting on a greasy ointment, there are a lot of other options. There are liquids, there are creams, there are new foams and sprays that go on and dry right out.
Now they’ve got the cortisone medicines into shampoos, so you can just put the shampoo in, leave it there for 10 minutes, and it gets the cortisone into the scalp.

Ross:
Are there any side effects with topical treatments that people should be aware of?

Dr. Feldman:
With our strong cortisone medicines, you could thin the skin out if you overuse them. If you catch it (skin changes) early and stop it, then the thickness of the skin would come back. That’s the biggest side effect of all.

There is a very, very rare side effect where if you rub enough cortisone on your skin, your brain thinks, “Hey, there’s already cortisone there, so the adrenal gland doesn’t need to make any.” And eventually the adrenal gland gets weaker at making the normal cortisone needed for daily life. But that’s an exceedingly rare side effect, one I have not seen.

Ross:Let’s talk about another psoriasis treatment, phototherapy. That involves exposing the skin to ultraviolet light.

Dr. Feldman, what are some of the current options for phototherapy?

Dr. Feldman:If one has more psoriasis on their body than they can put topicals on, I think the next best thing to do is phototherapy because you can treat the whole skin at once. And there are a lot of options.

There’s ultraviolet B light, which is the burning rays of the sun given in a controlled fashion in a doctor’s office. There’s a new form called narrow-band phototherapy that seems to be a little more effective, and you only have to come into the office three times a week.

It’s still a hassle for people, but coming-in to the office is the worst part of it. It seems to be very safe. Long-term studies of psoriasis patients haven’t shown any increased risk of skin cancer from ultraviolet light treatments.

The big deal is it’s hard to get off of work or find the time to come into a doctor’s office. Some people don’t live close enough to a dermatologist’s office with a light therapy unit to make good use of it.

There are a number of companies now that make home light units. They might run in the range of 2,000 to 6,000 dollars, depending on how fancy and expensive a unit you want to get. The less expensive ones might just be a four-bulb panel that would hide behind the door of a bedroom or something. You close the door of the bedroom, shine light on one side of the body, turn around and do the other side to get your light treatment.

Ross:
How much time would you spend getting the phototherapy like that?

Dr. Feldman:
You might start with a minute, work up to five, maybe 10 minutes per treatment. Start off low, and then go up a little bit higher each time as your skin gets used to the light.

There are different forms of this home light. There’s the UVB (ultraviolet B) and the UVA (ultraviolet A) light units. We’re predominantly using the UVB. The UVA light is sometimes used in a doctor’s office in conjunction with a pill called Psoralen. This pill sensitizes your body to the light. It is a more powerful way of treating psoriasis, but it’s also a little more risky. There is more risk of skin cancer with this treatment. But if you’ve got fairly dark skin, it seems to be a fairly safe thing. The people who are most at risk for skin cancer are people with lighter colored skin.

Now, there’s another form of light treatment - just going out in the sun. If you’re a teenager and you think, “Oh, man, I’ve got psoriasis now, and I’m going to have it a long time,” you might consider going to college somewhere on the coast, maybe Southern California or Florida. It helps keep the psoriasis under control.

Then there’s the final form of light therapy that I like to talk about that many dermatologists might not want me to be talking about, and that’s just going to a tanning bed salon.

Ross:
I was going to ask you about that. I wondered what the difference was between the phototherapy treatment and a tanning salon.

Dr. Feldman:
There are a number of differences. In the office, we give UVB light. In a tanning bed, it’s a little unpredictable. It depends on what kind of bulbs they use. It’s going to be mostly UVA. There might be some UVB in it. In a doctor’s office, it’s going to be carefully controlled. They’re going to set two timers. They’re going to have a trained phototherapist. At the tanning salon, they’re not going to have anybody medically trained to supervise things.

The theory is the tanning bed lights will make you dark but don’t really help the psoriasis. Two studies have looked at tanning beds, and they did find the tanning bed to be effective. Now, they weren’t well-designed, placebo-controlled trials, but the patients thought they were working. The doctors who did the studies thought they were working. I did one of the studies, and it seemed like it worked pretty well.

You could probably get an unlimited tanning plan for a month for about $50 or so. It might be about the same as the cost of the co-pay on one or two office phototherapy visits. With the tanning bed, the hours are more convenient. Because there are usually so many more of them in a town than doctors who have light boxes, they’re usually more conveniently located.

Ross:
So tanning beds might be a little less expensive. They might be a little more accessible for people, depending on where they live.

Now, you mentioned in terms of phototherapy, the slim possibility of skin cancer. Are there any other side effects one should consider when using that form of therapy?

Dr. Feldman:
If they’re on a photosensitizing drug for their blood pressure or something, they could be at increased risk of burning. Sunburn-like reactions would be the main thing. Be sure to tell your doctor about all the medications you are taking.

There is a risk to your eyes with cataracts. We always have people wear eye protection with whatever kind of light they’re getting.

Ross:Some patients don’t respond to the topical treatments or to the phototherapy. So for them, they might get a prescription for a systemic medication. Could you talk briefly about some of the current systemics?

Dr. Feldman:
In terms of the pills, there are three common ones: Soriatane (acitretin), methotrexate and cyclosporin (Neoral, Sandimmune).

Soriatane is a vitamin A derivative. It’s not very effective for your typical plaques of psoriasis, but it makes light treatments a lot more effective. That’s my main use of it, giving people a low dose of it to make the lights a more effective treatment.

Unfortunately, it causes severe birth defects if it’s in your body and you become pregnant. It’s obviously not a big problem for guys. It’s not a big problem for women who had a hysterectomy or they’re past menopause. But for women of childbearing potential, it’s a terrible choice because it stays in your body for a long time and causes a potential for birth defects.

It has a number of other annoying side effects that mostly occur with high doses. It’s going to sound like this is a really scary drug, but in the low doses we use we don’t see a whole lot of these side effects. But the side effects are depression, hair loss headaches, dry eyes, trouble seeing in the dark, dry nose, nosebleeds, dry mouth, dry and itchy skin, dry and achy joints.

The Red Cross cannot use your blood if you use this medication because they don’t want to give it to a woman who might be pregnant. It can make liver function blood tests go up. It can affect the blood triglyceride levels, making the fat levels in the blood go up and then the severe birth defects. But that’s the whole list, if I’m not mistaken, pretty close to the whole list.

Most of them are annoying side effects. Death was not one of the side effects.

The next drug would be methotrexate. This one has a risk of death. Methotrexate poisons your body’s ability to make DNA. Originally, they thought it slowed down the growth of the skin cells in psoriasis. It probably has more effects on the immune system. It may have other effects through receptors that I’m not sure are very well-defined yet.

They say it has a risk of death. I’ve got a lot of patients on it. It’s been around for 50 years. We know how it kills people. We know how to monitor it. We have to do blood tests because it can turn off the bone marrow and prevent the formation of red and white cells and platelets if you get too high a dose. It can destroy the liver, so you have to measure the liver enzymes. Some people believe we have to do biopsies of the liver every few years if you’re on it long-term to make sure we’re not hurting the liver. It can damage the lungs. There’s probably a small risk of developing certain cancers, like the cancer of the immune system, lymphoma, when you’re on methotrexate.

But overall, many dermatologists feel pretty comfortable with it since most of us have been using it for years. We’re careful to monitor it, so we generally don’t see a lot of patients with many of those problems. I’ve seen two or three patients, who have had problems with methotrexate, and all were caught early enough, we stopped the drug, and they did fine.

Ross:
What other systemic medications are there that people should know about?

Dr. Feldman:One of the nice things about methotrexate is that it seems to work well for the skin and the arthritis that some psoriasis patients get because it inhibits the immune system. It’s a pill you just take once a week, so it’s very convenient.

The last of the pills that I want to discuss is cyclosporin. When we discovered that psoriasis is an immune disease, people realized that you can use immune-inhibiting drugs. The classic example of the immune-inhibiting drug is cyclosporin. Cyclosporin revolutionized kidney transplants. The biggest problem was that the body would reject the new kidney. By giving patients cyclosporin, you basically cut down their immune system, and they don’t reject their kidneys anymore.

We use it in patients with psoriasis in somewhat lower doses. We don’t turn off the immune system to quite the same degree, and we can control the psoriasis. The problem with cyclosporin is that it causes high blood pressure, and it slowly destroys the kidneys in a fairly regular way. If somebody’s on it for more than a year or so, the cyclosporin will damage the kidneys.

Unfortunately, psoriasis is not a one-year disease. For many of these patients, it’s a lifelong problem. Cyclosporin’s great if you need treatment for a couple of months. If you’re going to get married in a month and you want to be clear, cyclosporin would be one of our fast ways of clearing you up for the wedding. But we don’t want to leave you on cyclosporin forever.

You take it probably twice a day, and you have to have blood tests at regular intervals. It’s a nice drug for people whose psoriasis suddenly got worse and they need something for a short time to get it back under control.

Ross:There are newer psoriasis treatments called biologics. Could you talk a little bit about them and how they might be better than some of these traditional treatments we’ve been hearing about?

Dr. Feldman:
The scientists at the NIH and at major drug companies and universities around the country have been studying how the immune system works. There are cells in the immune system, and there are proteins that the cells use to send signals to one another. There are proteins on the surfaces of these cells so that they can come into contact and interact with each other. Scientists gradually are developing a better and more specific understanding of the immune system.

As they tease out the proteins that are used by these cells to communicate with each other or to hold cells together so that they can communicate, they come up with a new target for controlling the immune system. So you discover a protein involved in the immune system, you make an antibody to it. That antibody can be used as a drug to block that part of the immune system, and then immune diseases like psoriasis or rheumatoid arthritis may be improved.

Drug companies are investing millions of dollars in psoriasis research, coming up with great, new treatments. The first of the ones that was specifically approved for psoriasis was a drug called Amevive (alefacept). It was designed to block one of the proteins that holds the immune cells together and is involved in activating the immune system. I’m not exactly sure that’s how the drug works, but that’s what it was designed to do. The drug’s an antibody or an antibody-like molecule, and it blocks this interaction in the immune system.

It doesn’t work for everybody. But in those people who it does work for, it seems to be a very safe treatment. So far we haven’t really seen any major side effects of this drug. It seems like it does help the arthritis, too, for some patients.

But you can’t take these drugs as a pill. You can’t eat these drugs because these drugs are like antibodies. They’re made of protein. And if you ate them, your stomach would chew them right up. So these drugs have to be injected into the body. Amevive is injected once a week for about three or four months in a doctor’s office. Some patients do great, and they stay clear for a good long while. For those patients who respond to Amevive, they often come back wanting another series of injections when their psoriasis comes back.

The next injection drug I’d talk about would be something called Raptiva (efalizumab). It’s another one of these antibody drugs that blocks one of the proteins that the cells use to hold each other together. When your white blood cells are circulating in the blood, they have to bind to the wall of the blood vessel to get out of the blood. Raptiva blocks that process. It also blocks one of the interactions necessary for the immune cells to become activated.

It’s given once a week at home by a shot underneath the skin, just like some people would inject insulin into their skin. Unlike a diabetic who has to inject themselves twice a day or something, Raptiva is injected once a week.

There are some rare effects on the blood. Blood tests are done at baseline, every month for a few months, and then maybe every three to six months after that. It seems to work pretty well for the skin. It doesn’t seem to do much for the joints. There has been some talk about being very careful when you stop it. If you stop it too suddenly and don’t do something else to control the psoriasis, the psoriasis can come back sometimes even worse than it was before you started.

Ross:
Now, are there other biologics besides Amevive and Raptiva that people should know about?

Dr. Feldman:
The most commonly used biologics for psoriasis are drugs that inhibit something called tumor necrosis factor (TNF). These drugs were first approved as arthritis treatments for people with rheumatoid arthritis, but quickly they discovered they work for psoriasis. Some of them work for people with inflammatory disease in their colon, what we call Crohn’s disease.

There are a number of them. One is Enbrel (etanercept), which is given by injection at home once or twice a week. Another one is Humira (adalimumab), which is given by a shot at home every other week, usually. The third one is Remicade (infliximab), which is given every few months in a doctor’s office by infusion through an initial course of three treatments.

They work great for the joints as well for the skin, which is really nice because so many of our psoriasis patients have joint involvement too.

Then there’s the safety risk. Anything that’s going to be doing something to your immune system is going to have some safety risk. Clearly, there’s an increased risk of infection in people who are on these drugs. If there’s a sign of infection, it’s better not to start them. If there’s an infection worse than a cold or a mild viral infection, then it’s probably a good idea to maybe stop these drugs for a little while until the body recovers.

In fact, it’s recommended that people get a tuberculosis (TB) test just to make sure that they don’t have tuberculosis latent in their bodies before starting on one of these drugs. There are some more rare side effects. Potentially, there is an increased risk of developing a cancer whenever you affect the immune system. I think that’s pretty uncommon with these drugs. Rare neurologic conditions, like multiple sclerosis (MS), have been reported.

Ross:
Dr. Feldman, I understand one side effect might be on your pocketbook when it comes to these biologics. They can be pretty expensive, can’t they?

Dr. Feldman:
Sadly, the cost of medications continues to increase and increase. When we look at the topicals, it’s nice. We have generic medications that work pretty well. Then, we have some newer ones such as Taclonex (calcipotriene/betamethasone dipropionate), which is a combination of a cortisone medicine and a vitamin D analog all in one. So the patient who really wants to be cost-conscious can try the generics first. If they want to invest a little money for something a little less messy, they can do that.

With phototherapy, the office treatments are kind of expensive. But the tanning is a pretty inexpensive way of dealing with things.

When it comes to the pills and injections, methotrexate is pretty cost-effective. With it, you probably could keep psoriasis under control for about $2,000 a year, including all the lab tests you have to do and office visits.

With Soriatane (acitretin) and cyclosporin, I used to think of those as very expensive drugs costing something like $8,000 to $10,000 a year. Now, that sounds like a lot of money, but these new injectable biologics make those others sound kind of mild. These new biologics can weigh in at $18,000 to $20,000 a year. And if for some reason you needed a double dose of one, you might be talking in the $30, 000 a year range.

Ross:
I understand that some insurance companies can help cover that cost, but that some will not. Is there any assistance for people who could really use the biologics but simply can’t afford that amount?

Dr. Feldman:Some insurance covers the costs, and some insurance they don’t cover at all or they may put hurdles suggesting the patient try methotrexate or some other light therapy first.

If the patient is completely uninsured, a lot of these companies are very happy to help the patient.

Other ways for the uninsured to get treatment might be to participate in a study. There are so many of these drugs, and they’re trying to find people to test them. That’s another option.

Then there are some people who are caught in the middle. They might have insurance, so the drug company may not feel be obligated to give them free medicine. However, their co-pays might be so high or the insurance company might deny coverage for the biologics. It might make it very hard for people.

There has been some foundation support that helps people get the medicine. One of the interesting things about these high-cost biologics is that the high cost makes it so that these companies provide extra good service. So they’ll give you a telephone number to call. And if you give the company permission to talk to your insurer, they will look into options for you to try to help you find access to medication.

Ross:Let’s take a look at the horizon. What kinds of treatments are currently in development? Do you see any exciting advances that might be coming online in the not-too-distant future?

Dr. Feldman:
In the not-too-distant future, there are more of these biologics coming. They are coming out with new antibodies all the time.

There’s one signaling molecule in the immune system called interleukin-12 and its related chemical, interleukin-23. A couple companies have made antibodies to this, and they seem to be very effective psoriasis treatments. However, they’re still in development. I think in the very long run, as we understand the genetics of the immune system and of psoriasis itself, we’re going to understand what really causes this disease. Then, maybe we’ll have some treatments that are really specific to the disease and aren’t just manipulating the immune system as a whole.

Ross:
We’ve been talking about a variety of therapies. Now, if a patient is on a therapy and it’s just not working for them, it’s not working out, what’s the best way for them to approach their doctor to talk about switching to another kind of treatment?

Dr. Feldman:Well, step one, get educated about what the options are. The National Psoriasis Foundation is an organization of people who have psoriasis, who want to know what the options are, who want to share the information. It’s a great way to find out what the options are and come prepared when you speak to the dermatologist.

If you have topical therapy and you really haven’t been using it that well because for whatever reason, be honest with the doctor. I think often the patients will come to see me and say, “Doctor, I’ve been using this medicine religiously. It just doesn’t work anymore,” when in fact, they may not be using the medicine. I don’t mind if they’re not using it all that well, but I need to know what it is about the medicine that they don’t like so I can help them plan a treatment that really fits better for their lifestyle.

Ross:Now were going to answer some questions that we received. We’re going to begin in North Palm Beach, Florida. The question is, "Is there any other treatment other than topical creams or liquids for scalp psoriasis?"

Dr. Feldman:I know at least one company that has an ultraviolet light comb. It has a comb that helps get the light down to the scalp. And I know of another company that’s trying to develop a newer model of that. When I was talking about light treatments, I was talking about light treatments for the whole body. However, they do make some hand-held units and some ultraviolet light lasers that can be used in the office for shining light on individual spots.

Dermatologists have found over the years that scalp psoriasis is one of the absolutely most frustrating forms of psoriasis for the patients and for dermatologists. Dermatologists like to see our patients get better, and scalp psoriasis often just does not get better with the topical treatments.

I’ve seen patients who’ve tried all sorts of things, all the different cortisones in solutions and foams and oils, and they’ve tried combinations of things with tar in them for their scalp. It’s just terrible what these people go through. Most of the time, the reason the scalp psoriasis doesn’t get better is because not one of those treatments was tried long enough to make it work. Knowing how much more difficult it is to get medicines on the scalp than to rub them on the elbow, it seems that many of these medicines aren’t working just because they aren’t getting used enough.

I have patients use the medicine twice a day for just three days. If they do that, they can see dramatic improvement in their scalp psoriasis.

Ross:
Our next question is from Blythewood, South Carolina. The question is, “My daughter is taking Enbrel (etanercept) for psoriatic arthritis. She’s been on it for nine months. She’s now 17 years old. She asked me if she’ll have to stay on it all her life. What’s your thought on that? It’s worked great for most of the psoriasis, but she still has some patches that are not going away. Is there something topical she do to help get rid of the remaining patches?”

Dr. Feldman:
Psoriasis is unpredictable, and so sometimes you get it and it’s there the rest of your life. Sometimes you get it, and it goes away. I would say that most of the time when you get it that young, you’ve got genes for psoriasis, and the psoriasis is probably going to be there for many, many years. It may not be there forever. But more likely than not, it will be there for the foreseeable future.

Enbrel has been around for a few years, so we feel pretty comfortable with it long-term. However, it hasn’t been around 20 years. We’re going to have to see what happens, whether it remains effective over time and if other side effects that we don’t know about start popping up.

If the Enbrel has gotten her psoriasis down to a much more manageable level, you can do any of the more traditional things to knock out the rest of it. You could do ultraviolet light treatments if there are a lot of spots. If there are just a couple spots, you can use one of the topical treatments.

Ross:We now have on the line Sandra from North Carolina. Sandra, thanks for joining us. What’s your question?

Caller:
I’ve had psoriasis now for about 40 years. I’ve been on topical things. Then, I tried the PUVA treatments and found that PUVA was the best to control my psoriasis. For the last four years now, I have MS. So I was wondering, what can I use to combat both of them?

Ross:
Dr. Feldman, is there something that could handle both of those for Sandra?

Dr. Feldman:If the PUVA’s working well for you and you’re not developing side effects, maybe it’s a good treatment long term. One of the problems with PUVA is that it sets the skin up for the development of skin cancer, so I’m a little nervous about using immune-inhibiting drugs later on because of the possibility that it might let more skin cancers pop up.

I don’t know of any treatment for MS that is also a treatment for psoriasis. We tend to manage those things in parallel with the neurologist who’s treating the patient.

But it’s very interesting that one would have that combination. We talk about the possibility that those TNF inhibitors like Enbrel can cause somebody to develop multiple sclerosis, but it’s so rare we really don’t know if it isn’t a random phenomenon. If you have psoriasis and MS, maybe there’s some link between the two, and maybe the TNF inhibitors have maybe very little to do with the appearance of MS in people with psoriasis.

Ross:
Our next question is from Norman, in Kissimmee, Florida, who asks, “I’d like to know about the effects of the long-term use of Vanos (fluocinonide). My doctor gave me a large quantity of samples when he told me I had hand psoriasis, but he said not to use it more than two weeks at a time.”

Dr. Feldman:
Vanos is one of those cortisone medicines, and it’s one of the strongest ones. So in theory, it can thin the skin out. Now with bad psoriasis of the palm, the skin of the palm is so thick that sometimes it’s hard to treat that area and to get topical medications to work. So we tend to use the highest potency ones in that situation. Very rarely do we see a whole lot of thinning of the skin of the palm from the cortisone medicines.

Now, on the back of the hands or on the forearms, the sun-exposed part of the forearm, yes, these strong cortisone medicines can thin the skin out over the course of months. But on the hands, we often use these strong cortisone medicines.

If you’re rubbing this kind of medicine over large parts of the body for more than two weeks, that could tell the brain there’s enough cortisone in the body from the absorption of it that it would tell the adrenal glad that you don’t have to make cortisone anymore. Then, the adrenal gland might get weak. So if there’s a sudden need for cortisone in this situation, the adrenal gland might not be able to handle it.

Ross:
Let’s go to Madison, Wisconsin. We have someone in Madison who writes to us, “Kenalog shots work to make my psoriasis go away for as long as six months. It does not come back any worse, but it does come back. My doctor is unwilling to give me the shots but once a year. Why is that?”

Dr. Feldman:
Well, Kenalog (triacinolone acetonide) is a strong cortisone medicine. When it’s taken internally, it can have that effect on the adrenal gland. If it’s in the body long enough, it can also weaken the bones. I don’t know if using the drug only twice a year is enough to weaken the bones or not.

It might be worth getting a bone density scan if someone were thinking about regular Kenalog injections as a way of managing their psoriasis. If there was no sign of any weak bones, maybe it’s appropriate. If there is a sign of weak bones, maybe taking calcium along with one of those new bone-sparing drugs like Fosamax (alendronate sodium) might help strengthen the bones and keep them in good shape despite the regular cortisone injections.

With the injections, I think one could worry more about the effects on the adrenal gland than maybe one would be with topical therapy.

Ross:Hamilton in Alabama writes, “At the moment, I’m taking Enbrel shots for my psoriasis, and the shots are working, but will I have to take the shots for the rest of my life so that I don’t have to deal with psoriasis?”

Dr. Feldman:
This is a common question that people on Enbrel must be asking themselves. And the answer is we don’t know. If the psoriasis is doing well, one might consider every few years cutting back on the Enbrel and seeing if one can get off it. If one hasn’t tried ultraviolet light treatments in the past because they thought it was too inconvenient to come to a doctor’s office, one might think about trying a home light unit or tanning bed for a while and see if that does the trick.

Ross:
Let’s go to Marionette, Wisconsin, where we have this question, “For almost a year now, I’ve been receiving Remicade (infliximab) treatments for psoriatic arthritis, and it’s also cleared my skin of severe psoriasis. But the treatment is not approved for psoriasis alone, only psoriatic arthritis. What can we do to change this? My body was covered about 90 percent. I dread the day I won’t be able to receive Remicade.”

Dr. Feldman:
To get the FDA to approve the drug for psoriasis as opposed to psoriatic arthritis, the company has to do major studies and prove that it works well for psoriasis without having too much in the way of side effects. The company has actually done that. While Remicade used to only be approved for psoriatic arthritis, it is now approved for psoriasis as well. This approval is fairly new.

However, Humira (adalimumab) is not approved for psoriasis. Right now, it’s approved for psoriatic arthritis. However, it is not yet approved for psoriasis.

Ross:
We have another question about Remicade from Yuchi in Chicago, “After having psoriasis from head to toe, every inch of my body, my psoriasis is being managed using Remicade, since 2003. If treatment is stopped, will it come back in its original intensity?”

Dr. Feldman:
It’s completely unpredictable. It may be that the Remicade could be stopped, and one would have a remission for some indeterminate period of time, maybe forever. It could be that it would come back with a vengeance. Unfortunately, I can’t predict which of those it would be.

They did a recent study, one of the studies that got Remicade approved. In the study, they gave some people Remicade every two months like clockwork. Then, the other people got the drug only when they needed it, kind of intermittently. The individuals, who got it regularly, did better with fewer side effects. So the dosing the FDA recommended was the every two months.

Remicade probably is not a drug I would want to experiment too much with in terms of timing of it and all. It might be okay to stop it, but I wouldn’t want to have a whole lot of stopping and restarting over time because I’d be afraid it would become progressively less effective over time and cause some more side effects.

Ross:
We have another question from Illinois, from Lisle. Lisle asks, “I currently take a 50-milligram dosage of Enbrel twice a week. Are there any new biologics or meds coming out that are required less often but are equally effective and self-administered?”

Dr. Feldman:
That would be Humira. Humira seems to be as effective as that double dose of Enbrel. The dose of 50 milligrams twice a week is the recommended dose for the first three months, but then it’s 50 milligrams once a week. Almost all the safety data, the vast majority of the safety data that we have on Enbrel, relates to using 50 milligrams once a week.

Humira, given every other week, seems to be about as effective, maybe a little more effective, than the twice-a-week Enbrel dosing. So that’s one-fourth as many shots.

Ross:
T. Seacrest in San Diego, California writes to ask you, “Currently, I don’t have health insurance. Is there any medication that I can purchase that does not require a prescription?”

Dr. Feldman:In much of the country, you can buy coal tar, over-the-counter tar ointments in the drugstore. It smells bad and stains things. If that doesn’t bother you, you can use a tar product without a prescription.

Moisturizers seem to help psoriasis. California has some special laws about selling drugs that potentially could cause cancer, and at least for a time they were thinking about taking tar off the shelves in California because there’s some slight increased cancer risk with it.

The main treatment for psoriasis that somebody in California can get without a prescription is ultraviolet light treatment, and it can be very effective for many people with psoriasis. If you live in a sunny climate, you can use the sun. You can go to a tanning bed without a prescription, and that can work great.

Ross:
Our next question is this, “I was diagnosed with psoriasis in 2002, a very mild case. It appeared while I was pregnant with my second child. Since then, it’s become a lot worse.

I have since been diagnosed with Graves’ disease, hyperthyroidism. My thyroid was out of control before I discovered it. Within that time is when my psoriasis got worse. It seems as though nothing works. I’ve had radioactive iodine treatment, and I’m currently trying to get my thyroid stable. My question is, will the psoriasis get better once the thyroid becomes normal?”

Dr. Feldman:It’s a great question, and you’ll find out when you normalize the thyroid. However, I don’t know. It may be that the elevated thyroid is just feeding the immune system, feeding the psoriasis, but it may have been completely unrelated, and we’ll have to see.

Ross:Our next question is from Seaford, New York. “My son, 11 years old, was diagnosed with psoriasis. He has numerous medications which aren’t working, partly because we aren’t as diligent as we should be in doing the oil treatment and/or putting the creams on his head daily. Who wants to medicate a kid daily? I was reading something about diet being a trigger. Could foods like pizza be triggers?”

Dr. Feldman:
I guess in theory, for any particular person, there could be some trigger that’s specific to trigger psoriasis. However, none of the dietary studies have shown any significant changes in psoriasis. There was one large study where they gave people large quantities of fish oil, and still they couldn’t detect any significant change in the psoriasis. We just finished a trial of a nutritional supplement, and there didn’t seem to be a whole lot of benefit in that one either.

If you see that there’s something that makes things worse, take that food out of the diet.

Ross:
Is there anything else besides the oil treatment and creams that they’re using in Seaford, New York that might be more amenable to an 11-year-old?

Dr. Feldman:If there are lots of spots all over the body, the ultraviolet light treatments would be completely reasonable to try. If it’s in the scalp, that’s one of the places we typically use the oil. The oil’s kind of messy. But if you don’t mind it, it usually doesn’t sting and is pretty good.

If the kid will put up with the stinging, then one of the generic cortisone liquids probably would be fine. There’s also that new shampoo, the Clobex shampoo, and it works pretty well. You put it in, you leave it there for 10 minutes, and then you rinse it out.

The key thing is to find one that’s the least bothersome and use it really well for a few days straight - just for a few days and see how much improvement you get.

Ross:
Betty in White Plains, New York writes to us, “How close are scientists to finding medications that will treat psoriasis without suppressing the whole immune system?”

Dr. Feldman:
We have ways of suppressing parts of the immune system now. We’re not suppressing the whole thing. But it would be nice not to have any increased risk of infection.

Amevive (alefacept) seems to be very safe. The Soriatane (acitretin) works without any significant adverse effect on the immune system. It gets rid of a lot of the scale, makes the lights more effective. The light treatments don’t seem to affect the immune system much.

I think we’re decades away from genetic advances that will tell us what’s causing psoriasis and will lead to treatments that improve the disease without affecting the immune system in a really broad or general way.

Ross:Dr. Feldman, is there anything that we haven’t asked you that’s important for people to know? Do you have any final thoughts for us?

Dr. Feldman:
Well, one of the things many people with psoriasis want to know is how to find a good doctor. First, you want to start with a dermatologist. Dermatologists know a lot about psoriasis. Some are more interested than others. The National Psoriasis Foundation Web site has a function on it that helps people find a dermatologist in their area, and they show what psoriasis treatments are being offered.

Another thing I think people want to know is whether they are seeing a good doctor, a good dermatologist. I started a Web site called drscore.com. This is a Web site where people can go and give their doctors feedback. Fill out a little survey. Give their doctor a score. The site shows what the doctor’s scores are. Once there’s enough ratings in, then people will really be able to compare their doctors.

Ross:
Dr. Steven Feldman, thank you so much for being so generous with your time. We appreciate you being with us.

Dr. Feldman:It’s my pleasure. Thank you.

Ross:
And thanks to all of you for listening. From HealthTalk, I’m Ross Reynolds.

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